OB-GYNE MOD 16

TRANS 3
III: Obstetric Hemorrhage
OUTLINE CLASSIFICATION (PARTIAL VS COMPLETE)
1. Uterine Rupture (Page 1)
2. Placenta Abruptio (Page 6) • Classified based on the anatomic layers
3. Placenta Previa (Page 12)
4. Vasa Previa (Page 16)
5. Guide in the diagnosis of vaginal bleeding (Page 6)
6. Simple Task (Page 17)
7. Cases 2021 (Page 18)
8. Paste 2021 (Page 20)
9. Paste 2020 (Page 22)

UTERINE RUPTURE
Figure 1. Uterine rupture – break in the uterine wall
OBJECTIVES
1. To diagnose correctly the common obstetric PARTIAL
hemorrhages in the second half of pregnancy
2. To correlate the different sonographic features with the • Visceral peritoneum is intact, Uterine dehiscence
diagnosis
3. To describe briefly the pathophysiology of each
condition
4. To identify the risk factors that may contribute or
associated in the development of these conditions FROM Lecturer
The outermost layer is intact, the innermost layer, the endometrium
5. To formulate an acceptable management plan for each
and myometrium separate. This is also called “Uterine Dehiscence”
condition among pregnant women

INTRODUCTION
The lecture is about bleeding in the second half of pregnancy.
Obstetric hemorrhage is one of the top 3 causes of maternal
deaths worldwide and more frequently the single most common
cause of maternal mortality in the developing country like ours
and more so in underdeveloped countries.

Obstetric Hemorrhage: Top 3 causes of maternal deaths:

• Uterine Rupture
Figure 2. (L) Image of partial uterine rupture (R) Image of Uterine
• Abruptio Placenta dehiscence
• Placenta Previa

FROM Lecturer
The common hemorrhages in the second half of pregnancy are
Uterine Rupture, Abruptio Placenta, and Placenta Previa.

CASE Figure 3: Partial uterine rupture in sonography and laparoscopy

32 years old G2P1 Ultrasound result will reveal that the defect in the entire placental
thickness is seen in the area of the CS scar. This may be detected during
39 weeks AOG
prenatal surveillance. If seen, one would notice a defect in the surface of
Labor pains the uterine wall, a depression may be present plus a discoloration of the
Previous CS a year ago lesion.
VS: BP 110/80mmHg (other VS were normal) , FHT was 140bpm
IE: Fully Dilated, Fully effaced, Cephalic, Station +4, (-) BOW
Severe abdominal pain after some time
Repeat BP- 60mmHg palpatory, FHT was not appreciated
Minimal to moderate bleeding per vagina

OBSTETRICS AND GYNECOLOGY: III: Obstetric Hemorrhage

Dr. F. Salvador 1/23
OB-GYNE: III: Obstetric Hemorrhage
COMPLETE
• All layers involved
• The entire 3 layers separate, including the visceral
peritoneum.
Figure 3. Complete uterine rupture
PATHOGENESIS
Figure 4. Pathogenesis of Uterine Rupture
FROM Lecturer
Uterine rupture is brought about by the (1) thinness of the uterine
wall due to prolonged labor, external factors like (2) uterotonics,
and (3) a presence of a scar. The break will either involve the entire
thickness of the uterine wall (endometrium, myometrium and
serosa) or it will only involve the inner 2 layers (endo, myo).
MODULE 16 TRANS 3
ANOTHER TYPES OF CLASSIFICATION (PRIMARY VS
SECONDARY)
PRIMARY
Figure 5. Primary type of uterine rupture
• Conditions like dystocic labor or fundal pressure was
applied over the uterus
• The rent might be along the lateral aspect of the corpus or
it may extend to the cervix or even the bladder
• May happen along the anterior or posterior wall, or it may
extend longitudinally or upward towards the fundus or
towards the entry of the uterine arteries
SECONDARY TYPE
Figure 6: Secondary type of uterine rupture
• There is already an existing or previous scar or incision on
the uterine wall
• Or an injury or a congenital anomaly of the uterus
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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
To further elucidate, we have two types of Cesarean Section
(CS)
FROM Lecturer
On examination, you will see the fetal part maybe out of the uterus
such us the lower or upper extremity, the fetal head, or sometimes
the whole fetus together with the intact fetal membranes are
extruded out into the abdominal cavity

Figure 8: Types of cesarean section

1. First is the Classical type, wherein the incision is

longitudinal or located at the corpus. The corpus is a
fake muscular structure than can contract. Once the
patient has contractions, this scar has a very strong
tendency to separate.

2. The second one is a low transverse Cesarean section

wherein the incision is located at the lower uterine
segment

Figure 7: Secondary type of uterine rupture FROM Lecturer

PREDISPOSING FACTORS
It is important to note in the history the predisposing factors. It will
be your clue in the diagnosis of uterine rupture.
Risk factors are divided into antepartum and acquired.
In a non-pregnant uterus, what is the counterpart of the lower
uterine segment? ANSWER: It is the isthmus, which is not a
muscular portion of the uterus. This has a lesser tendency to
rupture.

ANTEPARTUM
Surgery involving the myometrium
• Cesarean delivery
• Previous repair of the uterine rupture
• Myomectomy
• Deep cornual resection of interstitial Ectopic
[pregnancy]
• Metroplasty
• Hysteroscopy

1. CESAREAN DELIVERY

FROM Lecturer Figure 9: Previous cesarean section. This is a case of a

The scar may not be adequately repaired or the patient underwent previous cesarean section which upon opening revealed a
prolonged labor before consult was made. So, for our case, in our glistening membrane on the area of the CS scar. This is a
history, if it be recalled that there was a prior cesarean section. uterine dehiscence of a previous CS scar.
Another important data in our history is the interval of the first
pregnancy to the present. The previous pregnancy is less than 18
months or to be exact is one year only. So, the integrity of the scar
at this time may be questionable

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
2. REPAIR OF A PREVIOUS UTERINE RUPTURE
• A uterine dehiscence or a rupture of a previous CS with
a repair, has a greater chance of a repeat rupture. This
occurs about 1 to 2 weeks early of the previous event.

Figure 12. Cornual ectopic pregnancy

Figure 10. Rupture of a previous uterine rupture
4. METROPLASTY
3. DEEP CORNUAL RESECTION OF INTERNSTITIAL
ECTOPIC PREGNANCY • This is done to a uterus with a congenital anomaly.

• There are several types of ectopic pregnancy

o Ampullary
o Cervical
o Cornual – focusing on cornual ectopic
pregnancy which is shown in the encircled
picture (figure 11). The procedure is to make
deep incision involving the myometrium near
the lumen of the fallopian tube inside the uterine
cavity, this will create a scar that may be prone Figure 13. Metroplasty of Bicornate uterus with left and right
to rupture. hemicornum. (R) Shows the uterus after metroplasty with scars
o Interstitial and adhesions marking the previous incisions. These lesions are
also prone to rupture.

5. HYSTEROSCOPIC PROCEDURE

Figure 14: Hysteroscopic procedure.

• This procedure is done visualizing the inner uterine
cavity wherein a resection or the removal of the
endometrial polyp or submucous myoma is done.
• When the portion of myometrium is included during the
resection this may also create a weakness in the uterine
wall. This is done transvaginal.
Figure 11. Types of Ectopic Pregnancy

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OB-GYNE: III: Obstetric Hemorrhage
6. COINCIDENTAL TRAUMA
• Abortion with curettage beyond myometrium
o same condition may apply with hysteroscopy; a
portion of myometrial layer may be included
during the curettage.
• Vehicular trauma
o one would note in your history that the patient
figured in a vehicular accident. The countercoup
mechanism of the trauma may be applicable to
the patient, wherein the rupture may occur at the
posterior uterine wall.
Figure 15. Vehicular trauma in uterine rupture
CONGENITAL
• Occurrence of pregnancy in an underdeveloped horn.
Figure 16: Rudimentary horn
FROM Lecturer
Pregnancy may develop in the unprepared congenital lesions like
unicornuate uterus, and pregnancy may develop in the
rudimentary horn. But pregnancy year cannot be supported during
the advancing gestation and most likely may resort to uterine
rupture even in the early gestation.
MODULE 16 TRANS 3
ACQUIRED
• 2nd major type
• Includes:
o Accrete Syndromes
o Presence of Large Myoma (Myoma Uteri)
o Presence of Gestational Trophoblastic
Neoplasia
1. ACCRETE SYNDROMES
• Accrete syndromes or Morbidity Adherent placenta
Figure 17. In accrete syndromes the placenta has developed
beyond the myometrium up to or beyond the serosa.
Figure 18. Sonographically, accrete syndromes can be
diagnosed by some distinct features like presence of
vascularities overlying the placenta. In the scan there are a lot of
colors which represent the arteries and the veins. The uterus will
present with prominent vessels in a thinned out area with the
placenta underneath.
2. PRESENCE OF LARGE MYOMA (MYOMA UTERI)
• For very large myoma, the myoma doesn’t go along with
the myometrial contraction. In the interface of the
junction of the myoma and the normal myometrium
creates a difference in the tension.
• Rupture may happen even antepartum or during labor.
Figure 19. Myoma Uteri
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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

Figure 20. Sonography (L) and gross (R) myoma uteri.

Figure 22. ECG. Bradycardia HR-60bpm

3. PRESENCE OF GESTATIONAL TROPHOBLASTIC
NEOPLASIA

DIAGNOSIS

• A high index of suspicion FROM Lecturer

o Based on a good clinical history about previous
delivery and uterine operations may strongly During cadiotocogram, there will be signs of fetal distress. A non-
reassuring fetal heart rate pattern maybe recognized. Initially, from
point to the development of uterine rupture.
a normal heart rate of 120-160bpm to severe fetal heart rate
o During internal examination, the presenting part
deceleration pattern may be present which gradually may
is not appreciated transform into a prolonged bradycardia, then finally undetectable
heart rate. There will be cessation of uterine contractions. See the
left most arrow in Figure 22. The uterus cannot be anymore
palpated abdominally
FROM Lecturer
• Feto-maternal compromise
Four our case, the patient felt a severe pain. A repeat IE revealed
absence of the presenting part (big arrow in figure 21) from the
station of +4, the presenting part becomes floating, or cannot be
digitally examined. The fetus with the uterine contents may be totally
or partially extruded out in the abdominal cavity. FROM Lecturer

Before the occurrence circulatory collapse in a gravid patient the

maternal tachycardia and hypovolemia will be noted. Even if there
is no bleeding from the vagina because of the hemorrhage that will
occur within the abdominal cavity otherwise the condition maybe
presents with profuse vaginal bleeding.

The outcome of the baby is usually not good there is an increase

perinatal morbidity or mortality and sometimes if the fetus survives
there might be a neurological deficit due to prolonged hypoxia.

Figure 21. Absence of presenting part MANAGEMENT

• Laparotomy- deliver
• Non-Reassuring fetal heart rate pattern o (Immediate) Laparotomy or opening the
• Loss of uterine contraction abdomen requires very quick decision to deliver
the baby once a uterine rupture is recognized.
o It should be less than 17 minutes.
• Repair/hysterectomy
o for uterine preservation for patients with low parity
and young. If the rupture can be repairable once
the degree of rupture has been assessed, do
hysterorrhapy.
o Hysterectomy can be done in multiple gravidas if
the patient has completed his reproductive
career.

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
• Replacement of blood loss
o correction of anemia, due to acute blood loss, by
blood transfusion of the necessary blood
components is always part of the management.

KEY POINTS
• A good clinical history and a complete physical
examination must be done on the patient.
• High index of suspicion
o Support from the sonography and other ancillary
procedures like the cardiotocogram may be requested
• The immediate decision to deliver the fetus must be
taken into consideration to save the baby and the mother
from adverse outcomes.
o Note: Know the predisposing factors and have the Figure 23. Types of Abruptio Placenta
proper timing to refer the patient to a specialist.
TYPES OF HEMORRHAGE
PLACENTA ABRUPTIO • External
o Blood is extruded out of the uterus or the vagina
INTRODUCTION o Bleeding insinuates
The incidence of abruptio placenta remains the same despite the
• Concealed
decrease of fetal deaths from all other causes. The perinatal o Blood is retained between the placental plate and
mortality rate of abruptio placenta is higher than the combined
uterine wall
perinatal rates in the general population.
o Does not escape out
o Seen less commonly

CASE SCENARIO

• 24-year-old G1P0
• Full term
• Hypogastric pain
• VS – 170/110 mmHg, FHT not appreciated
• Abdominal findings: (+) tenderness, strong,
contractions q 1-2 min
• IE: cervix is 1-2 cm dilated, 50% effaced, cephalic, (+)
BOW, station 0 with no bleeding
We have a case of 24-year-old G1P0, term pregnancy who
complains of severe hypogastric pain. Her blood pressure is
170/110 mmHg. Fetal Heart Tone was not appreciated.
Contractions occurred every 1-2 min, strong, lasting for 60
seconds. Internal examination revealed cervix was soft 1-2
cm anterior, uneffaced or 2.5 cm long, cephalic in
presentation, intact bag of water, station 0 with no bleeding.
Figure 24. Type of Hemorrhage
(L) External hemorrhage; (R) Concealed hemorrhage
PATHOLOGY
• It is initiated by the rupture of the spiral artery to cause
hemorrhage in the decidua basalis.
• It is followed by the formation of the retroplacental clot.
• It may separate the decidua basalis from the myometrium
that may happen at the periphery or at the central portion of
the placenta.
• Lastly, the retroplacental hematoma compresses the
placental plate.

PLACENTA ABRUPTIO
Placenta Abruptio is the separation of the placenta from its
normal implantation before the delivery of the fetus.

CLASSIFICATION
• Partial
o Portion or some of the cotyledons are detached.
• Complete/Total
o Entire placenta is separated

Figure 3. Pathogenesis of Abruptio Placenta

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
severe, the formation of the blood clot, it will entirely
separate the attachment of the placenta and from
the uterine cavity it will compress outwards the
placenta until it detaches out into the cervix and out
into the vaginal vault.

• Macro view of placental separation

o Myometrium retraction of placental surface
forces blood out into the decidua basalis
placenta sheared off of its attachment
o The process of abruptio usually coincides when there
is a condition which promotes myometrial contraction.
o There will be a retraction of the placental surface since
there will be a maintained site of the permanently
positioned placenta (because of the immovability of
Figure 4. Pathogenesis of Abruptio Placenta placental plate) while there is decreasing site on the
First is the rupture of the spiral artery then there is formation of the myometrium (since the myometrium can retract or
retroplacental clot. The retroplacental clot separates at the decidua expand during myometrial contraction).
basalis from the myometrium and at one point in time the clot can now
compress the placental site or the placental bed.
CLASSIFICATION: BASED ON SEVERITY
• In 2019, the various classification of abruptio placenta
was proposed based on severity.

FROM William’s Obstetrics Table 1. Classification of Abruptio Placenta

1. Discovery of blood Class 0
• Etiopathogenesis clot Asymptomatic
o Partial or total separation of the placenta from the 2. Diagnosis is made
implantation site before delivery. retrospectively
o Latin term aburptio placentae.
o Symptoms may be absent at early stages.
o Initiated by hemorrhage into the decidua basalis. The
1. No sign or small Class 1
decidua basalis then splits, leaving a thin layer
amount of vaginal Mild
adhered to the myometrium. Consequently, the
bleeding
process begins as a decidual hematoma and expands
2. Slight uterine
to cause separation and compression of the adjacent
tenderness
placenta. Inciting causes of many cases have been
3. Maternal BP and HR
posited. The phenomenon of impaired trophoblastic
are normal
invasion with subsequent atherosis is related in some
4. No signs of fetal
cases of preeclampsia complicated by abruption
distress
(Bronsens, 2011).
o Inflammation or infection may be contributory 1. No sign or with a Class 2
(Mhatre,2016; Nath,2017). moderate amount of Moderate
o Histological finding cannot be used to determine timing vaginal bleeding
of the abruption (Chen, 2017) 2. Significant uterine
tenderness w/ tetanic
contractions
3. Maternal BP and HR
are normal
4. Evidence of Fetal
FROM 2021 distress
(same lecturer) 5. Hypofibrinogenemia
1. No sign to heavy Class 3
• Process of abruptio amount of vaginal Severe
o Rupture of spinal artery Hematoma (or a blood bleeding
clot) Separation Compression 2. Tetanic contractions/
o It will take some time to create a blood clot. If it is board-like rigidity
very recent you will not see any depression of the 3. Maternal hypovolemic
cotyledon (on the maternal side). But if it is shock
prolonged then you will see a depression on the 4. Hypofibrinogenemia
cotyledon. That’s why abruption is actually after a and coagulopathy
few hours of the formation of the blood clot. If it’s so 5. Fetal death

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

Past Trans
(same lecturer)

• Vaginal bleeding – Class I is None to Mild

o None – concealed type
o Mild – may be an external type of abruption
• Uterine tenderness
o Difficult to monitor pregnant women with labor
pains or uterine contractions. You must have a few
minutes to observe the patient to notice if the
patient is at the peak, onset, or the end of
contraction or in noncontracting status Figure 25. Friedman’s curve
Labor course divided functionally on the basis of dilatation and descent
o Contracting state: Filipinos can tolerate up to 5 cm
curves. (William’s Obstetrics 24th Ed.)
cervical dilatation (with discomfort, tolerable pain)
o For some with as early as 2 cm dilatation, pain RISK FACTORS
grade is at 8 or 9/10. Pain is intolerable It is important to know the risk factors present in the patient. This
o For moderate to severe: the slightest touch is might give a lead in the working impression of the case.
already painful and then goes into relaxation
o In normal early labor, 1-2 cm dilatation cannot feel • Prior Abruptio
any pain and the patient is comfortable. If you find o A history of a previous abruption might be a
a patient with pain at 1cm, you may suspect guide. This occurs 1-3 weeks early than the
abruptio because 1 cm is not compatible with a first abruption.
severe degree of pain. You have to think about the • Increased parity and maternal age
congruence of dilatation and degree of pain. o They are likely to experience more than the
o Most painful is usually at 8-10cm and in younger women
Friedman’s curve, the fetus must be descended on
• Preeclampsia
the pelvic cavity already at 8cm. The pain is more o There is an increase pressure noted in the
than the early part of labor. inferior trophoblastic invasion in the case of
o Very tender – abdomen does not relax. It has a preeclampsia. The spiral arteries elicit medial
board-like rigidity on palpation layer contractions.
o Contractions only lasts for seconds. Average: 50-
• Chronic hypertension
60 seconds, longest may be 90 seconds
o There is a greater risk because of the reduced
o After, there are periods of relaxation for blood to
intravascular fluid volume on top of the
flow into the uterine artery to go into the placenta. hypertension.
For abruptio placenta, it is very firm all throughout
• Chorioamnionitis
the abdomen.
o Inflammation or infection leads to weakened
o How to know if firm or not: Firm – feel the knees or
membranes.
any bony prominence; Soft – depress the cheek or
• Preterm/premature rupture of membranes
deltoid area
o Tensile strength of the membranes is
• Maternal Vital signs
decreased
o Class III: the patient will be pale, BP will drop below
• Multiple gestation
80, and patient cannot be talked to. Before, there
o The principles of uterine stretch leads to
will be a period of restlessness. This happens
activation of contraction associated proteins or
when patients go into shock, restless -> becomes
CAP. Which may also lead to uterine activation
unconscious (because the patient is hypotensive).
and cervical ripening.
This condition might be irreversible at this time.
• Low birthweight
• Presence of coagulopathy
• Polyhydramnios
o Normal fibrinogen levels: 150-350 mg/dL
o Also uses the principles of uterine stretch.
o Abruptio: factors would be less than 150 mg/dL
• Cigarette smoking
o Class III- fibrinogen levels are lower. The
o There is an association BUT mechanism is
coagulopathy that could happen is DIC.
unknown.
• Fetal Status
o Maybe it is due to the decreased placental
o Class I: no fetal distress or normal HR
blood.
o Class II: fetal distress or w/ tachycardia
o Nicotine has vasoconstrictive effects on
o Class III: fetus might be dead already
uterine and umbilical arteries as well as
increase in carboxyhemoglobin concentration
that hinders oxygenation.

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
o Micro infarctions may develop in the placenta 2. Fibrinogen level
leading to formation of thrombus or necrotic 3. D-dimer
foci. 4. Cardiotocography
o Evidences of hypoxia such as fibrin and 5. Blood work-up
thrombus were demonstrated by Kanitzky et al
during the 2008. ULTRASOUND
• Cocaine use • Limited
o Produces dose dependent hypertension and • What would you like to search in the ultrasound?
uterine vasoconstriction. o We have to look for the thickened area in the
• Presence of myoma if unusually large and located at placenta or hypoechoic area in the placenta which
the submucous area can cause a disparity in the may represent the retroplacental clot
contraction of the uterus on both sides of the opposite • Sonographic findings:
sides of the myoma. o Thicker placenta
o Hypoechoic areas
SIGNS AND SYMPTOMS

• Pregnant women present with sudden onset of abdominal

pain not compatible with the late stage of labor on
examination uterine contractions (hypertonic) are tetanic
and very strong and they do not attain the baseline non
conducting State.
• There is uterine tenderness upon palpation of the
abdomen. Internal examination usually presents an early
dilatation finding.
• A lot of cases have a non-reassuring fetal status. Which
means either the fetus could be tachycardic and/or
extremely bradycardic.
• There can be also vaginal bleeding where patient may
appear pale representing circulatory compromised.
Figure 27. Sonographic findings
DIAGNOSIS This picture shows the findings in the ultrasound of a recent abruption in
which you would see a thicker placenta. There is a darker than usual
area around that area (YELLOW CIRCLE) in which we call that a
• The diagnosis for severe type of abruption is not difficult the hypoechoic area which may represent the retro placental hematoma.
presence of sudden abdominal pain, uterine tenderness
and board like rigidity of the abdomen are common. FIBRINOGEN LEVEL
There are also possibilities of frequent uterine • (301-696 mg/dl) late
contractions, non-reassuring fetal status/ fetal
• You can have a lower amount of fibrinogen level to as low
distress.
as 150 or 250 mg/dl because the normal value in the third
• The profuse vaginal bleeding is common to others but in the trimester of pregnancy is 300-600 mg/dl. This could also be
instances of mild abruption with minimal symptoms the a late finding.
diagnosis is by exclusion.
D-DIMER
• This may also confirm your abruptio placenta

CARDIOTOCOGRAPHY
• Late
• You would be able to appreciate the non-reassuring fetal
heart rate pattern such as tachycardia or bradycardia
• Cardiotocogram
o Fetus showing bradycardia to loss of fetal heart rate

Figure 26. Placental Abruption

DIAGNOSTIC MODALITIES

Aside from a thorough history, the diagnostics that may be of

value are the following:
1. Ultrasound

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3

COMPLICATIONS
CONSUMPTIVE COAGULOPATHY
• Since there is a release of thromboplastin into the maternal
circulation, one of the complications is consumptive
coagulopathy
• Causes consumption of procoagulant factors, leading to the
activation of the clotting
• Increase levels of D-dimers
• Decrease levels of fibrinogen, or higher levels of fibrinogen
products

END-ORGAN FAILURE
• Acute kidney injury (AKI)
Figure 28. Cardiotocogram o Due to severe hypotension, wherein the blood supply
This picture shows the cardiotocogram findings. The result of the fetus to the important organs are compromised
is showing bradycardia to even the loss of the fetal heart rate • Sheehan’s syndrome
o Hypoperfusion of the pituitary
BLOOD WORK-UP o Loss of axillary and pubic hair
• CBC o Difficulty to breastfeed
• Blood typing o Episodes of oligomenorrhea to amenorrhea
• Prothrombin time o Weight gain
• Activated partial thromboplastin time
• Other blood parameters COUVELAIRE UTERUS
• Uterus is visualized with a seepage of extravasated blood
into the myometrium, fallopian tubes, ovaries, and broad
ligament serosa
• Not an indication for hysterectomy
FROM Williams Obstetrics 24th ed.

• Unfortunately, there are no laboratory tests or other

diagnostic methods to accurately confirm lesser
degrees of placental separation.
• Sonography has limited use because the placenta and
fresh clots have similar imaging characteristics.
• Negative findings with sonographic examination do not
exclude placental abruption.
• Conversely, magnetic resonance (MR) imaging is highly
sensitive for placental abruption, and if knowledge of
this would change management, then it should be
considered. Figure 30. Couvelaire Uterus
• With abruption, intravascular coagulation is almost
universal. Thus, elevated serum levels of D-dimers may MATERNAL AND FETAL MORTALITY
be suggestive, but it has not been adequately tested.
• Hypovolemic shock, if severe enough, may cause
maternal and fetal mortality

William’s Obstetrics 24th ed.

Consumptive coagulopathy
• An important consequence of intravascular coagulation
is the activation of plasminogen to plasmin, which lyses
fibrin microemboli to maintain microcirculatory patency.
With placental abruption severe enough to kill the fetus,
there are always pathological levels of fibrinogen–fibrin
Figure 29. A recently delivered placenta wherein there is still an degradation products and d-dimers in maternal serum.
attached retroplacental clot (labelled C) on the maternal side of the
placenta

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OB-GYNE: III: Obstetric Hemorrhage
Acute Kidney Failure
• In obstetrics, it is most commonly seen in cases of
severe placental abruption in which treatment of
hypovolemia is delayed or incomplete.
Sheehan’s Syndrome
• Rarely, severe intrapartum or early postpartum
hemorrhage is followed by pituitary failure.
• Findings include failure of lactation, amenorrhea, breast
atrophy, loss of pubic hair and axillary hair,
hypothyroidism, and adrenal cortical insufficiency.
Couvelaire Uterus
• At the time of cesarean delivery, it is not uncommon to
find widespread extravasation of blood into the uterine
musculature and beneath the serosa.
• Effusions of blood are also seen beneath the tubal
serosa, between the leaves of the broad ligaments, in
the substance of the ovaries, and free in the peritoneal
cavity.
Hypovolemic Shock
• Caused by maternal blood loss
• Massive blood loss and shock can develop with a
concealed abruption.
• Prompt treatment of hypotension with crystalloid and
blood infusion will restore vital signs to normal and
reverse oliguria from inadequate renal perfusion.
MANAGEMENT
• Depends on:
o How advance the labor is
o Age of Gestation
o Maternal indication
o Fetal Indication
§ Whether there is compromise or not
§ Whether the pregnancy can be prolonged
FROM William’s Obstetrics 24th ed.
• Treatment of the woman with a placental abruption
varies depending primarily on her clinical condition, the
gestational age, and the amount of associated
hemorrhage.
• With a living viable-size fetus and with vaginal delivery
not imminent, emergency cesarean delivery is chosen
by most.
EARLY AMNIOTOMY
• When seen early, this procedure has always championed
the initial management of placental abruption.
o Advantages:
§ Decreases the intrauterine pressure
§ Better spiral artery compression
MODULE 16 TRANS 3
• Useful decrease in implantation site
bleeding
§ There is membrane rupture which may hasten
delivery
§ Achieves better uterine contraction
§ Reduces thromboplastin release into the
maternal circulation
IMMEDIATE DELIVERY
• If the fetus is still alive, immediate delivery should be done.
o In early labor, cesarean might be done
o In cases of possible imminent delivery, may wait for
vaginal delivery
o In cases of non-viable fetus, (or not alive), might wait
for vaginal delivery, especially when the mother is
stable.
Williams Obstetrics 24th ed.
• Cesarean Delivery. The compromised fetus is usually
best served by cesarean delivery, and the speed of
response is an important factor in perinatal outcomes.
• If the fetus has died, then vaginal delivery is usually
preferred.
• Placental implantation site depends primarily on
myometrial contraction and not blood coagulability.
Thus, after vaginal delivery, uterotonic agents and
uterine massage are used to stimulate myometrial
contractions.
• There are exceptions for which vaginal delivery may not
be preferable even if the fetus is dead. For example, in
some cases, hemorrhage is so brisk that it cannot be
successfully managed even by vigorous blood
replacement.
• Obstetrical complications that prohibit vaginal delivery
such as a term fetus with a transverse lie are another
example.
REPLACEMENT OF BLOOD LOSS
• Replacement of blood loss can be done by using plasma
expanders.
FROM Williams Obstetrics 24th ed.
• Experiences indicate that maternal outcome depends
on the diligence with which adequate fluid and blood
replacement therapy are pursued rather than on the
interval to delivery.
• Women with severe abruption who were transfused for
18 hours or more before delivery had similar outcomes
to those in whom delivery was accomplished sooner.
12/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
PREVENT OTHER COMPLICATIONS
• There is prevention of complications (initiated by the
hypoperfusion or the hypovolemia of the patient) to avoid
FROM UpToDate
injuries to the important organs of the patient.
Placenta previa refers to the presence of placental tissue that
extends over the internal cervical os. Sequelae include the
potential for severe bleeding and preterm birth, as well as the
need for cesarean delivery.

CASE SCENARIO Placenta previa should be suspected in any pregnant woman

beyond 20 weeks of gestation who presents with vaginal
• 24-year-old G1P0 bleeding. For women who have not had a second-trimester
• Full term ultrasound examination, bleeding after 20 weeks of gestation
• Hypogastric pain should prompt sonographic determination of placental location
• VS – 170/110 mmHg, FHT not appreciated before a digital vaginal examination is performed because
• Abdominal findings: (+) tenderness, strong, palpation of the placenta can cause severe hemorrhage.
contractions q 1-2 min
• IE: cervix is 1-2 cm dilated, 50% effaced, cephalic, (+) CASE
BOW, station 0 with no bleeding • 35 years old G2P1
• 32 weeks AOG
What will be the management for this case? First what will • Vaginal spotting
you do? Since it is 1-2 cm dilated and then you do not know • Only 1 prenatal checkup during 1st trimester
if the fetal heart tone can be appreciated so you do • Smoker (1-2 sticks per day)
amniotomy, so you release intrauterine pressure. • Previous CS
• Bleeding noted upon waking up
What will be expected if you do amniotomy? • Normal vital signs
• You will note the character of amniotic fluid. • FHT 150bpm
• If it’s clear maybe the baby has not yet pass out • No uterine contractions
meconium so maybe the baby might be okay. • Reactive cardiotocogram
• It could be stained, or it could be blood tinged • Ultrasound revealed placenta previa
because of the retroplacental clot mixed with the
amniotic fluid so it depends on what is the character
of the amniotic fluid.

Once you release the intrauterine pressure you might be able

to appreciate the real status of the baby so will there be a
fetal heart tone or no fetal heart tone? If there is a fetal heart
tone what will you do?
• Since this is only 1-2 cm, you’ll do cesarean
section.
• If the case is about 9 or 10cm dilatation station plus
3 you just wait for vaginal delivery.
With the blood pressure of 170/110 mmHg you might give
antihypertensive drugs and magnesium sulfate.
FROM the Lecturer
A cardiotocogram was done and interpreted as with no
deceleration, no contractions but with acceleration.
PLACENTA PREVIA
• Implanted in the lower segment, over or very near the
internal cervical os
• Expanded 4-5cm nearing 3rd trimester

PLACENTA PREVIA
Before the advent of sonography, the diagnosis of placenta
previa is suspected among patients with vaginal bleeding, and as
consequent finding a placenta during actual internal examination
leading to torrential blood loss and greater risk of maternal and
fetal death.

Others practice a double set-up, wherein the patient is set-up at

the operating room, and will undergo internal examination, then
if it turns out that the patient has previa, cesarean section will
push through.

Figure 31. Placenta previa

13/23
OB-GYNE: III: Obstetric Hemorrhage
FROM the Lecturer
It is when the placenta is implanted in the lower uterine
segment. The lower uterine segment is the isthmus part of the
corpus during the non-pregnant state. It has expanded 4-5cm
nearing the 3rd trimester
CLASSIFICATION
PLACENTA PREVIA
1. Placenta Previa – placenta covers the internal os
completely
Figure 32. Complete Placenta Previa
2. Placenta Previa – placenta partially covers the internal os
(without crossing it)
Figure 33. Partial Placenta Previa
LOW LYING PLACENTA
• The placental edge is within the 2 cm wide perimeter
around the internal os but does not cross over it
Figure 34. Low lying Placenta
MODULE 16 TRANS 3
• This condition may change in a 1 cm dilated cervix,
becoming 5 cm in dilatation
o The placental edge now becomes partially
attached and is now transformed into a partial
placental previa
• Anatomical relationship is not precise in changes as the
pregnancy advances or even during labor.
PATHOLOGY
• Implantation of blastocyst in areas with good blood
supply and oxygenation
• Unfavorable conditions lead to development of
placenta previa
FROM the Lecturer
Technically, placenta previa when it bleeds, is premature
separation of an abnormally implanted placenta. The placenta or
portion of it becomes a presenting part. It is from the Latin word
previa which means going before. Early in pregnancy,
implantation of the zygote (blastocyst) prefers locations with a
good blood supply and oxygenation in the decidua basalis.
Unfavorable conditions allow the zygote with the developing
trophoblast to implant elsewhere.
PLACENTAL MIGRATION
• Normally, the growth is towards the fundus where there
is a good source of blood supply
o This is called Trophotropism
• In some conditions, placental attachment is favored at
the lower uterine segment (LUS)
• Placental edge encroached internal os, but a repeat
scan showed absence of encroachment
FROM the Lecturer
Placental edge is initially assessed to be covering the os. After a
repeat scan at around 35 weeks, showed absence of
encroachment. This is called PLACENTAL MIGRATION, but
actually is a misnomer. Widening of LUS towards end of the 3rd
trimester, wherein the placental lies close to the edge but
actually not over the internal os.
RISK FACTORS
• Maternal age - advance maternal age confounded with
conditions such as altered hormonal or implantation
environment.
• Multiparity - higher parity, probability of having several
uterine procedures like curettage or infertility work ups
• Cigarette smoking – nicotine and carbon monoxide
acts as vasoconstrictors of placental vessels thereby
reducing the oxygenation capacity.
• Leiomyoma – avoids an environment with decreased
oxygenation, so that it bumps off the zygote or the
blastocyst to other implantation sites.
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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
• Prior cesarean delivery (surgery) – at times the lower DIAGNOSIS: SONOGRAPHY
uterine segment surprisingly may provide an area with NORMALLY IMPLANTED PLACENTA
rich vascular supply since the lower uterine segment is
near the uterine arteries
• Assisted reproductive technology – Inflammatory
mediators and oxidative stress may bring about
defective decidualization of placental vessels and
uterine contractions caused by the pelvic adhesions of
endometriosis which may be associated with placenta
previa

CLINICAL FEATURES

The most important feature of placenta previa is Vaginal

Bleeding
• Painless vaginal bleeding - which begins without any
warning occurring with contractions
• Sentinel bleed - may not be profuse.
• Occurs late in 2nd trimester or later gestation
• Slight or profuse.
FROM the Lecturer
Other pregnancies have more bleeding throughout the prenatal
until labor begins.
The internal os dilates, and then some portion of the placenta
separates, since the lower uterine is non-contracting segment,
bleeding is poorly controlled, hence further bleeding continues.
Figure 35. Placenta with a normal location. GREEN line outlines
the placenta. RED line measures the distance of the placenta to
the internal os. YELLOW line marks the internal os.
In any vaginal bleeding, after mid-pregnancy, one always
consider placenta previa. A digital examination is not allowed
in placenta previa. If the patient is stable, a transabdominal scan
for placenta localization must be requested. If still the placental
edge is not visualized, one may resort to transvaginal scan
which is the gold standard. Now if available in hospital
institution, a color doppler may be more helpful. To label a case
placenta previa, the uterus must have developed a lower uterine
segment, usually around 28weeks AOG.

PLACENTA PREVIA

FROM the Williams Obstetrics 24th edition

Painless bleeding is the most characteristic event with placenta

previa. Bleeding usually does not appear until near the end of
the second trimester or later, but it can begin even before mid-
pregnancy. Bleeding from a previa usually begins without
warning and without pain or contractions in a woman who has
had! an uneventful prenatal course. In perhaps 10 percent of
women, particularly those with a placenta implanted near but not Figure 36. The cervical canal lined by the RED line. Placental
over the cervical os, there is no bleeding until labor onset. edge outlined by YELLOW line, showing the placental edges
Bleeding at this time varies from slight to profuse, and it may crosses over the internal os.
clinically mimic placental abruption.

Figure 37. Ultrasound with color flow mapping: moderate color

flow uptake signifying vascularities.

15/23
OB-GYNE: III: Obstetric Hemorrhage
Figure 38. Speculum examination of placenta previa showing
placental tissue.
Once it is known that there is placenta previa, NO INTERNAL
EXAMINATION must be done. But one may resort to do
speculum examination to possibly visualize placental tissue.
FROM the Williams Obstetrics 24th edition
Whenever there is uterine bleeding after midpregnancy, placenta
previa or abruption should always be considered. Diagnosis by
clinical examination is done using the double set-up technique
because it requires that a finger be passed through the cervix
and the placenta palpated. A digital examination should not be
performed unless delivery is planned. A cervical digital
examination is done with the woman in the operating room and
with preparations for immediate cesarian delivery. Even the
gentlest examination can cause torrential hemorrhage.
MANAGEMENT
FROM the Lecturer
The mode of delivery is always cesarean section. For pregnancy
before the period of viability, it has to be temporized.
• Tocolytics to control preterm labor
• Corticosteroids are also instituted to hasten lung
maturity
• Bed rest may also be advised to the patient
• Instances where in the bleeding is still profuse after the
delivery of the placenta:
o Cesarean hysterectomy may be done if the
bleeding compromises the mother
o Correction of anemia may be done even
before the delivery
o Units of blood should be readied during the
actual placenta previa operation
MODULE 16 TRANS 3
FROM Batch 2021’s Trans 2.2
• Cesarean delivery
o Primarily done to save the baby. If in case the baby
demised, continue CS to reduce risk for mother
(dead baby will not go out spontaneously)
• CS-hysterectomy
o If there is a presence of a morbidly adherent
placenta
o Remember the lower uterine segment is not the
contracting part of the uterus. Very thin siya, walang
myometrium. Also very near the bladder (Width:4-
5cm). That’s where you do the incision in CS.
o For young women, you do not remove the ovaries,
just the corpus.
• Blood transfusion
• Management is always operative whether the AOG is
28 weeks and the bleeding is profuse.
CASE
• Vaginal bleeding
• No uterine contractions
• Late second trimester or early third trimester
• Bleeding manifested during her rest
• Management: Cesarean section
FROM the Lecturer
The case presents with vaginal bleeding which is a sentinel
bleed. As reported in the cardiotopogram, the patient initially has
no contractions (that is why it was classified as painless). The
ultrasound scans definitely support the diagnosis of placenta
previa. Another feature of the case is that the patient had a
bleeding during the time of her rest. So, these are the typical
findings you may find when you take the history of a patient with
a diagnosis of placenta previa.
VASA PREVIA
CASE
A case of a 28-year-old, primigravid, full term, who came in due
to labor pains. Internal examination revealed 7 cm cervical
dilatations, fully effaced, cephalic in presentation, station 0 with
intact bag of waters. Amniotomy was done with clear AF which
became blood streaked later. Repeat FHT after some time
showed absence of fetal heart rate. She later delivered to a pale,
fresh, stillbirth fetus.
• 28-year-old G1
• Full term
• 7cm dilatation, cephalic, station 0 (+) BOW
• FHT – 140bpm
• Amniotomy done with clear to bloody AF
• Repeat FHT - 0
16/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
VASA PREVIA MANAGEMENT
Vessels run along the membranes overlying internal os
• After rupture or amniotomy • Control of preterm labor – given after 24-28 weeks AOG
• Will lead to fetal exsanguination because we don’t know when the patient will deliver.
o Tocolytics
o Corticosteroids
• Cesarean section – manner of delivery (always)

GUIDE IN THE DIAGNOSIS OF VAGINAL BLEEDING

FROM the Lecturer
Guide in the diagnosis of the causes of hemorrhages in the
In this condition, vessels travel within the membranes and overly
the cervical os. The vessels can be torn during a spontaneous second half of pregnancy.
rupture or during artificial amniotomy.

Type 1 Type 2
Vessels are part of Vessels span between the
Velamentous insertion where bilobate or succenturiate
the cord is attached to the placenta. There is presence of
membranes and not to the vessels between the main
placental bed placenta and accessory
placenta

Figure 41. Guide for diagnosis of causes of hemorrhage

Figure 39. Type 1 Figure 40. Type 2
Table 2. Types of Vasa Previa

FROM the Lecturer

RISK FACTORS Explanation of the diagram
Vaginal bleeding (Center) can be caused by 3 or 4 conditions.
• Placenta previa in 2nd trimester – where the lower
uterine has not fully developed yet. The first condition: if the patient presents with strong uterine
contractions, with uterine tenderness and difficult to appreciate
• In vitro fertilization
fetal heart tones, the BP might be normal or elevated, you think
of ABRUPTIO PLACENTA.
DIAGNOSIS So now if the patient presents with no contractions, but she has
expressed earlier that she had hypogastric pains or labor pains,
• Ultrasound – Color doppler and placenta previa was ruled out, IE may reveal a non-palpation
• Palpate vessel during IE or a very hard presenting part and fetus might be in distress or
with absent fetal heart tone, think of UTERINE RUPTURE.

Now if one is presented with bleeding but with no hypogastric

pain of any sort, the fetus has normal fetal heart rate and upon
FROM the Lecturer palpation of the abdomen, there is really no contraction, think of
Antenatally, Vasa previa can be seen in the initial transabdominal PLACENTA PREVIA BUT DO NOT DO IE.
scan. This can be later confirmed by a presence of vessels at the
internal os using color doppler. If a speculum examination was REFERENCES
done and the cervix is open, one may get lucky so that 1. References: Video lecture
visualization of the vessels is possible. If undetected, the 2. Books
condition is catastrophic to the fetus because of exsanguination; TRANSCRIBERS
hence, there should be high index of suspicion. Further diagnostic 1. TRANS GROUP: Meant 2B
tests like color doppler must be requested for low-lying vasa 2. SUBTRANSHEAD: Hannah Clarice Luciano
previa cases or those with cesarean scars.
De La Salle – Health Science Institute College of Medicine
Batch Twenty Twenty-Two
“non sibi sed omnibus”

17/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
C. Placenta Previa
D. Placental Abruption

8. What is the condition when placental vessels traverse the

internal os?
A. Placenta Previa
B. Velamentous Placenta
C. Vasa Previa
D. Bilobed Placenta

9. What is the surgical procedure when the abdomen is opened

up in the management of uterine rupture?
A. Cesarean section
SIMPLE TASK B. Laparotomy
*USE AT YOUR OWN RISK C. Hysterotomy
1. Regarding fetal heart rate decelerations, which of the following D. Hysterography
statements is correct?
A. Late decelerations are clinically benign. 10. What is the most significant risk factor that may lead in the
B. We can appreciate variable decelerations in patients with diagnosis of uterine rupture?
ruptured bag of waters A. Assisted reproductive technology
C. Late decelerations are caused by head compression B. Previous cesarean section
D. The nadir of fetal heart rate occurs after the peak of C. Curettage
contraction if the deceleration is early in character. D. Prior uterine rupture

2. The type of decelerations produced in a Contraction Stress CASES 2021

Test should be of ______ in character so that it will be valid for 1. A 27 year old G2P1 37 weeks AOG complained of
interpretation. hypogastric pain 30 minutes prior to consult. At ER, pertinent
A. Early PE showed BP 160/110mm Hg, HR of 89 bpm, RR of 18
B. Variable bpm, IE done after loading dose of Magnesium sulfate given
C. Spontaneous revealed 1-2 cm cervical dilatation uneffaced with minimal
D. Late show. Abdominal findings showed strong uterine
contractions every 1 to 2 minutes. FHT was 110 bpm. Based
3. The biophysical parameter that is last to appear is the _____
on this data:
A. Fetal tone
B. Fetal movement
C. Fetal heart rate reactivity What is the most likely diagnosis?
D. Fetal breathing Abruptio Placenta

4. Which of the following types of miscarriage may result in pelvic Give one differential.
inflammatory disease? Placenta Previa
A. Septic
2. A 39 year old G6P5 (5005) 38 weeks AOG complained of
B. Complete
C. Incomplete hypogastric pain 3 hours prior to consult. At ER, pertinent PE
D. Threatened showed BP of 200/120 mm/Hg, HR of 91 bpm, RR of 18
cpm, IE done after loading dose of Magnesium sulfate given
5. In which part of the fallopian tube does ectopic pregnancy revealed 3 cm cervical dilatation uneffaced with intact BOW
usually take place? cephalic station 0. Abdominal findings showed uterine
A. Ampulla contractions every 2 minutes, strong. FHT was 90 bpm.
B. Interstitial Based on this data:
C. Isthmus
D. Fimbria What is the most likely intervention that can be done to
help in the formulation of your diagnosis?
6. Which of the trophoblastic disease is benign?
A. Invasive mole Nonstress test/Biophysical profile
B. Complete H-mole - Simple procedure
C. Epithelioid trophoblastic neoplasia - Uses an ultrasound
D. Choriocarcinoma - Measure the baby’s breathing, muscle tone,
movement, and volume of amniotic fluid in the uterus
7. What is the condition when the placenta is implanted in an
abnormal location? A second abnormal blood pressure reading 4 hours after
A. Vasa Previa the first may confirm suspicion of preeclampsia. Blood and
B. Placenta succenturiata urine tests may also be done after.

18/23
OB-GYNE: III: Obstetric Hemorrhage
What is the most likely diagnosis? 6.
Preeclampsia
3. A 19 year old G1P0 at 36 6/7 weeks AOG complained of
vaginal bleeding 1 hour prior to consult. At ER, pertinent PE
showed BP of 180/110mmHg, HR of 85 bpm, RR of 18 cpm,
IE done after loading dose of Magnesium sulfate given
revealed closed cervix uneffaced Abdominal findings
showed uterine contractions every 2 minutes strong. FHT
was 120 bpm. A baseline cardiotocogram done; revealed a
nonreassuring fetal heart rate pattern. Based on this data:
What is the most likely diagnosis? 7.
Uterine Rupture
What is the management for this case?
Cesarean Delivery
4. A 31 year old G2P1 (0101) 37 weeks AOG known
hypertensive complained of labor pains 2 hours prior to
consult. Pertinent PE showed BP of 190/120 mmHg, HR of
93 bpm, RR of 20 bpm, IE done after loading dose of
Magnesium sulfate given revealed 9 cm cervical dilatation
fully effaced cephalic station +1 with ruptured BOW thickly
meconium stained with profuse bleeding. FHT was not
appreciated. At DR patient, delivered to dead baby boy BW
1.9 kg. Placenta delivered immediately following the baby. 8.
Based on this data:
Give your diagnosis.
Abruptio Placenta (severe)
Enumerate the salient points supporting your
diagnosis.
- Known hypertensive
- Pre-eclampsia (BP = 190/120)
- (+) PROM H ruptured BOW thickly meconium stained
- (+) profuse bleeding
- (+) labor pains 2 hours prior to consult 9.
- Delivered to dead baby boy BW 1.9 kg
5. A 31 year old G2P1 (0101) 37 weeks AOG known
hypertensive complained of labor pains 2 hours prior to
consult. Pertinent PE showed BP of 190/120 mmHg, HR of
93 bpm, RR of 20 bpm, contractions were strong occurring
every 2-3 minutes. IE done after loading dose of Magnesium
sulfate given revealed 2 cm cervical dilatation fully effaced
cephalic station +0 with ruptured BOW thickly meconium
stained with profuse bleeding. FHT was not appreciated. At
DR, patient BP revealed 80/60 mmHg, HR of 119 bpm, and
RR of 30 bpm. Patient appeared pale. Based on this data:
10. A 26 year old G2P1 38 weeks AOG consulted because
What is the most likely diagnosis?
Abruptio placenta
Give your management
a. cesarean delivery
b. vaginal delivery
c. replacement of blood loss
MODULE 16 TRANS 3
A 25 year old G1P0 at 32 weeks AOG consulted
because of vaginal bleeding. Her history was unremarkable.
PE showed a fundic height of 29 cm, FHT of 140 bpm, with
no contractions.
Give the most likely diagnosis.
Placenta Previa
Give your diagnostics.
Sonography
A 39 year old G7P5 (5015) at 37 weeks AOG consulted
because of vaginal bleeding. Her history was
unremarkable. PE showed a fundic height of 31 cm, FHT of
140 bpm, with no contractions. Ultrasound revealed
placenta overlying the internal os with presence of
sonolucency at the placental plate. Her blood type is O+.
Give your diagnosis.
Placenta Previa
Give your management.
- Close observation in obstetrical unit
- Cesarean delivery
A 19 year old G1P0 at 37 weeks AOG consulted because of
vaginal bleeding. Her history was unremarkable. PE
showed a fundic height of 34cm. FHT of 150 bpm, with no
contractions. Ultrasound revealed placental edge at the
margin of the internal os. Her blood type is A+.
Give the diagnosis
Placenta Previa
Give the management
Deliver via cesarean delivery
A 28 year old G2P0 at 39 weeks AOG consulted because of
vaginal bleeding. She has no prenatal check-up. PE showed
a fundic height of 34cm, FHT of 150 bpm, with no
contractions. Ultrasound revealed placental edge 2cm
beyond the internal os. Her blood type is A+.
Give the diagnosis
Complete Placenta Previa
Give the management
- Cesarean Delivery
- Blood transfusion
- Close observation in an obstetrical unit
of severe hypogastric pain. She still feels the fetal
movement. Her fundic height was 39 cm and her vital signs
were normal. Initial IE revealed: cervix 8cm dilated cephalic
station 0 intact BOW. After 2 hours she became restless and
complained of severe pain again. Repeat IE showed 8 cm
dilatation but presenting part became floating. FHT is 110
bpm.
19/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
Give the diagnosis. BhCG level was 1600 mIU/ml. What is your initial
Uterine Rupture impression?
Select one:
Give the management. a. Missed abortion
- Emergency exploratory laparotomy with Cesarean b. Threatened abortion
delivery c. Ectopic pregnancy
- Depending on the nature of the rupture and the d. Hydatidiform mole
condition of the patient
3. A 34 y/o primigravid, 11 weeks AOG, is rushed to the
11. A 36 year old G3P1 (1011) 36 weeks AOG consulted Emergency Room for vaginal bleeding and passage of
because of severe hypogastric pain. Her fundic height tapioca-like material per vagina. On abdominal examination,
was 41 cm and her vital signs were normal. She the uterine fundus is at the level of the umbilicus. What is
informed that she has an intramural myoma located your initial impression?
anteriorly, Initial IE revealed cervix 5cm dilated cephalic Select one:
station 0 intact BOW. During labor she further complained of a. Molar pregnancy
increasing pain. Repeat IE after 2 hours showed 5 cm b. Missed abortion
cephalic station H1. After IE profuse bleeding was noted. BP c. Incomplete abortion
then became 80/50 mm Hg. Uterine contraction was not d. Preterm labor
4. A 43 y/o, G6P5 (3023), 12 weeks AOG, is diagnosed to have
anymore appreciated
a molar pregnancy on transvaginal sonogram. What is the
Give the diagnosis preferred management?
Abruptio Placenta Select one:
a. Hysterectomy
Give the management b. Hysterotomy
Immediate delivery thru CS, followed by blood transfusion c. Chemotherapy
(packed RBC) d. Suction curettage

12. A 33 year old G4P3 (3003) 39 weeks AOG consulted 5. MD, 39 year old, G2P1 (1001) consulted the ER for labor
because of labor pains. She has normal vital signs and IE pains. IE was done which revealed a baby in cephalic
revealed 9cm dilatation cephalic fully effaced, station +1. At presentation and a cervix that is dilated to 7 cms, 60 – 80%
the DR amniotomy was done after which clear amniotic effaced, ruptured BOW. What type of deceleration will you
fluid was noted followed by bloody tinged AF. Repeat likely observe?
FHT done revealed 105 bpm. Further monitoring after Select one:
hydration revealed FHT of 80 bpm at CTG. a. Spontaneous deceleration
b. Variable deceleration
c. Early deceleration
Give your working diagnosis.
d. Late deceleration
Uterine Rupture
6. The components of a biophysical profile include all except
Give the management.
Immediate cesarean delivery which of the following?
Select one:
a. Amniotic fluid volume assessment
PASTE 2021
b. Fetal breathing
1. A 20 y/o, G2P1 (1000), 10 weeks pregnant, commercial sex
c. Contraction Stress Test
worker is rushed to the Emergency Room because of pelvic d. Fetal tone
pains and vaginal spotting. She was pale and tachycardic.
There is direct and rebound abdomen tenderness on the left
lower quadrant. On pelvic examination, a tender cystic mass 7. What is the characteristic sonographic picture of a molar
measuring 3 by 2 cm was palpated and the posterior fornix pregnancy?
was boggy. How will you manage this patient? Select one:
Select one: a. Predominantly hyperechoic
a. Give intramuscular methotrexate. b. Whorled pattern
b. Do CT scan of the abdomen. c. Hypoechoic
c. Prepare the patient for exploratory laparotomy d. Snow storm pattern
d. Observe the patient for progression of severity of
the pelvic pains 8. What is the common site of ectopic pregnancy?
Select one:
2. A 30 y/o, G1P0, 8 weeks pregnant, consults you for a. Ovary
hypogastric pain. Vital signs are stable. Cervix was closed b. Peritoneum
and the uterus was slightly enlarged on pelvic examination. c. Cervix
Pelvic sonogram showed an empty uterine cavity. Serum d. Fallopian tube

20/23
OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
b. Cigarette smoking
c. Maternal age
9. . What is the most common symptom of trophoblastic d. Increase BMI
diseases?
Select one: 16. What is the most cost effective way to diagnose placenta
a. Vaginal bleeding previa?
b. Abdominal pain Select one:
c. Headaches a. Transabdominal scan
d. Dyspnea b. MRI
c. 3D ultrasound
10. Which is true about Contraction Stress Test (CST)? d. Transvaginal scan
Select one:
a. Patient is placed in supine position 17. A 16 year old G1P0 on her 28 weeks AOG had a scanty
b. Contractions may be induced either oxytocin drip or bleeding. Placenta previa was signed out in her ultrasound
nipple stimulation findings. What would be the management for her case?
c. May be performed in patients who underwent Select one:
myomectomy or with a placenta implanted lower a. Give steroids then schedule for cesarean section
than the fetal presenting part b. Temporize pregnancy till 35 weeks AOG
d. May or may not perform NST prior to CST c. Give steroids then tocolyse until the maximum
period it can hold pregnancy
11. Which of the following statements is TRUE regarding a d. Do emergency cesarean section
complete h-mole?
Select one: 18. . A 32 year old G3P2 with no prenatal checkup presented at
a. Serum BhCG levels are low. the ER because of profuse vaginal bleeding with no note of
b. It has fewer number of vesicular placental villi. contraction. Maternal and fetal status were stable. The
c. Karyotype is triploid. fundic height is 33 cm. What is the initial management you
d. Risk for malignant degeneration is high. would request?
Select one:
12. Which of the following statements is TRUE regarding a. Emergency cesarean section
laparoscopy in the diagnosis and treatment of ectopic b. Transvaginal ultrasound
pregnancy? c. Give tocolytics
Select one: d. For vaginal delivery
a. Laparoscopy results in longer hospital stay and
recovery. 19. A 38 year old G4P3 diagnosed with placenta previa located
b. Laparoscopy may be done under local anesthesia. posteriorly on her 34 weeks AOG. She has no more desire
c. Laparoscopy is preferred over laparotomy in for another pregnancy. What would be the better plan for her
hemodynamically unstable patients. delivery?
d. Laparoscopy can be used in both surgical and
Select one:
medical treatment.
a. Classical cesarean section
b. Cesarean hysterectomy
13. A patient presented with scanty bleeding on her 28th week
c. Low transverse cesarean section with bilateral
of gestation. An ultrasound was done revealing placenta tubal ligation
previa. What is the most likely immediate management for d. Low transverse cesarean section
her pregnancy? Select one:
a. Secure blood during delivery 20. A 41 year old G1P0 on her term pregnancy breech
b. Placental color flow mapping presentation and with history of infertility was diagnosed with
c. Administer tocolytics anterior placenta previa. She was advised to undergo
d. Request for hepatitis Bs antigen cesarean section. The main reason for doing the cesarean
section is________.
14. Which ultrasound finding is a true placenta previa at 35
Select one:
weeks AOG?
a. History of infertility
Select one: b. Breech primigravid
a. Placental edge is at the margin of internal os c. Age
b. Edge of placenta located 1.5 cm from internal os d. Anterior placenta previa
c. Edge of placenta located 1.0 cm from internal os
d. Placental edge 2 cm beyond the internal os 21. . A 36 year old G5P2 was diagnosed with placenta previa
with loss of retroplacental zone between placenta and
15. The following are risk factors for the development of
uterine musculature during ultrasound. What is the most
placenta previa EXCEPT:
likely manner of delivery for this case?
Select one:
Select one:
a. Assisted reproductive technology

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OB-GYNE: III: Obstetric Hemorrhage MODULE 16 TRANS 3
a. Cesarean delivery with bilateral tubal ligation d. Ampulla
b. Cesarean delivery but leave the placenta
intrauterine ANSWER KEY: CCABC-CDDAB-DDBDD-DCBCD-DBCDB-
c. Cesarean delivery CD
d. Cesarean hysterectomy
PASTE 2020
22. A 40 year old G2P2 patient was trying to get pregnant after 1. A 29-year-old G3P2 (2002) at 32 weeks age of gestation with
5 years. She underwent assisted reproductive technology overt diabetes mellitus consulted at the OPD due to
and was successful. She had 2 previous cesarean sections. decrease fetal movement. Non stress test was requested.
For her delivery the risk of placenta previa with accreta is Which of the following findings is considered as reactive non
higher because of what condition? stress test?
Select one: a. Two accelerations of ≥ 15 beats per minute lasting for ≥
a. Age 15 seconds
b. Two previous cesarean sections b. One deceleration of ≤ 15 beats per minute lasting for ≤
c. Interval of pregnancy
15 seconds
d. Relative infertility
c. One acceleration of ≤ 15 beats per minute lasting for ≤
23. What is the abnormality seen that led to the development the 15 seconds
placenta accrete syndrome? d. Two decelerations of ≥ 15 beats per minute lasting for ≥
Select one: 15 seconds
a. Myometrium
b. Placental villi 2. A 38-year-old primigravid at 34 weeks age of gestation
c. Nitabuch layer complaining of decreased fetal movement. Which of the
d. Decidua vera following is the best antepartal surveillance for her case?
a. Modified Biophysical Profile
24. A G1P0 term pregnancy on her 5th hour of labor underwent b. Non stress test
amniotomy. The amniotic fluid was bloody tinged. After c. Fetal movement counting
which fetus showed fetal bradycardia. What is the most likely d. Contraction stress test
working diagnosis for this case?
Select one: 3. A 29-year-old G1P0 at 41 weeks AOG came in for prenatal
a. Placenta previa check-up. Vital signs were normal, FHT: 150 bpm, FH: 34
b. Uterine rupture cm, Leopolds maneuver showed cephalic presentation.
c. Abruptio placenta Internal examination revealed that the cervix is 1-2 cm
d. Vasa previa dilated, 50 % effaced, intact membranes and station 0.
Clinical pelvimetry was adequate. BPS- 8/10 with
25. A 31 year old G1P0 31 weeks AOG consulted for the first oligohydramnios. Contraction Stress test (CST) was
time at the OPD. IE was done after other physical requested and showed there were late decelerations in
examinations. There was a note of torrential gush of blood. every contraction. This trace is a/an __________?
What is the working diagnosis? a. Positive
Select one: b. Negative
a. Abruptio placenta c. Equivocal
b. Placenta previa d. Unsatisfactory
c. Vasa previa
d. Uterine rupture 4. Majority of ectopic pregnancies implant in the ____.
a. Cervix
26. During prenatal check-up, what is the most likely procedure b. Ovary
in the diagnosis of vasaprevia? c. Peritoneum
Select one: d. Fallopian tube
a. Transabdominal ultrasound with color flow
mapping 5. How does abnormal fallopian tube anatomy increase the risk
b. Transvaginal 3-D for an ectopic tubal pregnancy?
c. Transvaginal ultrasound with Doppler velocimetry a. It retards passage of the fertilized ovum into the uterine
d. Speculum examination cavity.
b. There is less inflammation around the area of the tube
27. . A 15 year old primigravid on her 10th week AOG was abnormality.
diagnosed to have ectopic pregnancy. What is the most c. Ciliary activity of the tube lumen epithelium is greater.
common site of ectopic pregnancy if the fallopian tube? d. It offers more surface area for blastocyst implantation.
Select one:
a. Isthmus 6. A 29 y/o, G3P1 (1011), 11 weeks pregnant, rushes to the
b. Infundibulum Emergency Room because of pelvic pains. She is pale and
c. Fimbria tachycardic. There is direct and rebound abdomen

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OB-GYNE: III: Obstetric Hemorrhage
tenderness on the right lower quadrant. On pelvic
examination, a tender cystic mass measuring 4 by 1.5 cm is
palpated on the right adnexal area. Posterior fornix is boggy.
How will you manage this patient?
a. Give intramuscular methotrexate.
b. Observe the patient for progression of severity of pelvic
pains.
c. Do transvaginal sonogram after an hour.
d. Prepare the patient for exploratory laparotomy.
7. A 30 y/o, G3P2 (2002), 9 weeks pregnant, consults you for
vaginal spotting and hypogastric pain. Vital signs are stable.
Cervix is closed on pelvic examination. Pelvic sonogram
shows an empty uterine cavity. Serum beta hCG level was
1100 mIU/ml. What is your initial impression?
a. Hydatidiform mole
b. Phantom HCG
c. Ectopic pregnancy
d. Miscarriage
8. A 36 y/o, G1P0, 11 weeks pregnant, consults for severe
pelvic pains and vaginal spotting. A 3 by 4 cms cystic mass
and peritoneal fluid in the posterior culdesac are seen on
transvaginal sonogram. Culdocentesis done is positive for
nonclotting blood. Which of the following is a radical
treatment for this condition?
a. Methotrexate
b. Salpingectomy
c. Salpingostomy
d. Salpingotomy
9. Which of the following statements describes the use of
laparoscopy in the diagnosis and treatment of ectopic
pregnancy?
a. Laparoscopy is preferred over laparotomy in
hemodynamically-unstable patients.
b. Laparoscopy may be done under local anesthesia.
c. Laparoscopy can be used in both surgical and medical
treatment.
d. Laparoscopy results in longer hospital stay and recovery
10. If the placental edge does not reach the internal os and
remains within a 2 cms wide perimeter around the os, the
placenta is:
A. Normally-implanted
B. Low-lying
C. High-lying
MODULE 16 TRANS 3
placenta to be partially covering the internal cervical os. The
route of delivery will be:
A. Vaginal
B. Abdominal
13. Which of the following is a risk factor for placenta previa?
A. Patient is 20 years old
B. Patient is a primigravid
C. Patient had a previous cesarean section
D. Patient drinks a glass of wine occasionally
14. The most characteristic clinical feature of placenta previa is:
A. Vaginal bleeding
B. Uterine tenderness
C. Uterus is tetanically contracted
D. Preterm rupture of membranes
15. A 27 y/o, G1P0, 34 weeks AOG, with low-lying placentamay
be closely observed in a maternal intensive care unit,
provided:
A. The presenting part is engaged.
B. Uterine contractions are irregular
C. There is no fetal growth restriction
D. There is no persistent active bleeding.
16. Which of the following is an etiology of vasa previa?
A. Preeclampsia
B. Oligohydramnios
C. Contracted pelvis
D. Previous cone biopsy of the cervix
17. A velamentous insertion of the umbilical cord into the
placenta makes a patient at risk for _________.
A. Uterine hypertetany
B. Chorioamnionitis
C. Maternal hemorrhage
D. Dystocic labor
18. A 22 y/o, G2P1 (2001), 37 weeks AOG, was found to have
vasa previa by transabdominal ultrasound. The route of
delivery of this patient is__________.
A. Vaginal
B. Abdominal
ANSWER KEY: AAADA-DCBCB-CBCAD-CCB

11. A 29 y/o, G3P1 (1011), 33 weeks AOG, is rushed to the

emergency room because of vaginal bleeding. Pelvic
sonogram done showed the placenta to be partiallycovering
the internal cervical os. What is your initial impression?
A. Complete previa
B. Low-lying placenta
C. Placenta previa partialis
D. Placenta previa marginalis

12. A 29 y/o, G2P0 (0010), 36 weeks AOG, in labor, consults

you for vaginal bleeding. Pelvic sonogram shows the

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